907 KAR 1:084.

Payment for medical assistance services furnished out of state.

 

      RELATES TO: KRS

205.520

      STATUTORY AUTHORITY:

KRS 194A.030(2), 194A.050(1), 42 C.F.R. 447 Subpart B, 42 U.S.C. 1396a, b, d,

EO 2004-726

      NECESSITY, FUNCTION,

AND CONFORMITY: EO 2004-726, effective July 9, 2004, reorganized the Cabinet

for Health Services and placed the Department for Medicaid Services and the

Medicaid Program under the Cabinet for Health and Family Services. The Cabinet

for Health and Family Services has responsibility to administer the program of

Medical Assistance. KRS 205.520(3) empowers the cabinet, by administrative

regulation, to comply with any requirement that may be imposed, or opportunity

presented, by federal law for the provision of medical assistance to Kentucky's

indigent citizenry. This administrative regulation sets forth the conditions

under which the Medicaid Program shall pay for covered medical services

furnished eligible recipients who are out of state.

 

      Section 1. General.

Medicaid services provided to an eligible Medicaid recipient who is a resident

of Kentucky while that resident is in another state shall be reimbursed in

accordance with Section 2 of this administrative regulation.

 

      Section 2. Criteria

for Coverage while Out of State. (1) Payment shall be made if covered medical

services are needed because of a medical emergency.

      (2) Payment shall be

made if medical services are needed because the recipient's health would be

endangered if he were required to travel to Kentucky for the medical service.

With regard to long-term care patients, it shall be the policy of the cabinet

to pay for the medical services only until the time when the patient's medical

condition has stabilized so the patient return to Kentucky; it is expected that

the period of coverage shall be sixty (60) days or less; continuation of

payment shall be contingent upon presentation of medical evidence acceptable to

the cabinet which justifies an additional stay in a facility outside the state.

      (3) Payment shall be

made when the state determines, on the basis of medical advice, that the needed

medical services, or necessary supplementary resources, are more readily

available in the other state; provided, however, that this provision shall not

be construed or interpreted in a manner which circumvents or negates the

provisions and intent of this administrative regulation.

      (4) Payment shall be

made when it is general practice for recipients in a particular locality to use

medical resources in another state.

 

      Section 3. Exception.

For individuals in long-term care out of state prior to the effective date of

this administrative regulation, and for whom the cabinet is at that time paying

for the cost of care, the cabinet may continue to pay for the cost of care if

the cabinet deems the payments to be appropriate. Children in subsidized

adoption or foster care status shall be exempt from the restrictions shown in

this administrative regulation.

 

      Section 4.

Cooperation with other States. The cabinet shall facilitate the furnishing of

medical services to individuals who are present in Kentucky and are eligible

for Medicaid under another state's Medicaid plan. (Recodified from 904 KAR

1:084, 5-6-86; Am. Ky.R. 1632; eff. 1-10-92.)